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Limitation of CR in detecting mid tarsal joint degenerative joint disease compared to US

Discussion in 'General Issues and Discussion Forum' started by Mart, Aug 10, 2012.

  1. Mart

    Mart Well-Known Member


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    I meet clinicians who seem unconvinced of value of B-mode high-resolution ultrasound compared to radiographic exam to investigate foot degenerative joint disease. I am posting an illustrative example for discussion. As usual I am keen to meet a contrary viewpoint; I believe that US may have greater value than CR as first line to investigate non traumatic midfoot pain.

    Presentation:

    • Referral from physiotherapist for non responsive foot pain. 60 yo female; denied prior foot surgery, persistent fairly severe bilateral dorsal midfoot pain worsening and of several years duration. Insidious onset and denied recollection of a traumatic event.
    • Primary care physician ordered recent radiographic exam radiology was reported normal.
    • Subsequent scintigraphy suggestive for degenerative joint disease but poorly specific for site.
    • Some pain on rising from bed in morning; worsens towards end of day.
    • Occupation as airport security officer requires constant standing and walking at work.
    • Reported being unable to exercise because of her foot pain.
    • Reported being in good general health.
    • Primary care physician prescribed Celebrex; this has been used for past four weeks without significant benefits so far.

    I observed:

    • Bilaterally some mild swelling and tenderness at dorsal midfoot, left greater than right. Provocative testing with double limb stance heel raise resulted in generalised dorsal midfoot pain

    non weight-bearing CRs of this case attached as .pdfs

    Point of this thread is to see if anyone can accurately detect site of degenerative joint disease from attached CR (I can't).

    View attachment example 1.pdf
    View attachment example 2.pdf
    View attachment example 3.pdf
    View attachment example 4.pdf
    View attachment example 5.pdf

    I will post US images as alternative to CR and scintigraphy for those interested after several days to illustrate value of US in this type of case.


    Cheers

    Martin


    Foot and Ankle Clinic
    1365 Grant Ave.
    Winnipeg Manitoba R3M 1Z8
    phone [204] 837 FOOT (3668)
    fax [204] 774 9918
    www.winnipegfootclinic.com
     
  2. Bruce Williams

    Bruce Williams Well-Known Member

    Mart;

    I only looked at the first and last image but I agree with you, I see no signs of DJD on those x-ray films.

    I'm interested to see the other images you post.
    Bruce
     
  3. Martin:

    I don't normally iniitally perform either x-rays, ultrasound, CTs or MRIs on these patients. I treat them as dorsal midfoot interosseous compression syndrome and 80% of them get better. If they don't improve, then I start with x-rays.

    Dorsal Midfoot Interosseous Compression Syndrome


    Do you, Martin, perform US, CTs, Xrays and/or MRIs on all patients with plantar heel pain? Just curious.
     
  4. Mart

    Mart Well-Known Member

    Thanks Bruce and Kevin.

    Kevin I normally follow your example with classifying as dorsal midfoot interosseous compression syndrome when others have ordered CR which showed no significant findings. In recalcitrant cases I always look for evidence of TMT synovitis with US specifically to rule out other issues and identify corticosteroid injection site.

    I always do US for plantar heel pain; I have taught my podiatry assistant to do this - a fast, simple, inexpensive way to rule out/confirm plantar fasciosis and also to identify distal plantar fasciosis which I tend to accommodate to avoid compression irritation from foot orthoses.

    US Images attached of US exam of CR examples posted at start of thread.

    Please post if anyone needs interpretation of these images which may be unfamiliar and not intelligible.

    US1.jpg

    US2.jpg

    US3.jpg

    US4.jpg

    Cheers

    Martin

    Foot and Ankle Clinic
    1365 Grant Ave.
    Winnipeg Manitoba R3M 1Z8
    phone [204] 837 FOOT (3668)
    fax [204] 774 9918
    www.winnipegfootclinic.com
     
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